Lords Sitting of 20 July 1921

Preamble
The House met at a quarter before four of the clock, The LORD CHANCELLOR on the Woolsack.
VISCOUNT CHELMSFORD.
The Rt. Hon. Frederick John Napier, Baron Chelmsford, G.C.S.I., G.C.I.E., G.B.E., having been created Viscount CHELMSFORD of Chelmsford in the County of Essex—Was (in the usual manner) introduced.
LORD PLUMER OF MESSINES.
Field-Marshal Sir Herbert Charles Onslow Plumer, G.C.B., G.C.M.G., G.C.V.O., having been created Baron PLUMER of Messines and of Bilton in the County of York—Was (in the usual manner) introduced.
TAF FECHAN WATER SUPPLY BILL. [H.L.]
Read 3ª, and passed, and sent to the Commons.
LONDON COUNTY COUNCIL (GENERAL POWERS) BILL.
Read 3ª, and passed, and returned to the Commons.

HOSPITAL FINANCE.
VISCOUNT BURNHAM VISCOUNT BURNHAM rose to ask His Majesty's Government whether they have fully considered the Report of Viscount Cave's Committee on hospital finance, and if so, what further steps they will take to put the system of voluntary hospitals on a more satisfactory footing, particularly in relation to Poor Law infirmaries.
The noble Viscount said: My Lords, I put this Question on the Paper, not in antagonism to the Committee presided over by the noble and learned Viscount, Lord Cave, to whom, I am certain, the whole hospital world is much indebted for the care that he has taken in the preparation of the Report. On the other hand, the Report is of necessity provisional, and the remedies suggested are in the nature of a stop
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gap. The Committee was appointed by the Minister of Health, as your Lordships' House knows, in order to deal with an acute and urgent phase of the hospital problem, which had necessitated the closing down of a great number of beds in London hospitals and thereby, of course, a decrease of the equipment and the opportunity for the treatment of the sick poor, at a time when their need is as urgent as it is to-day. The London Hospital has closed down 200 beds, and King's College Hospital has, I think, closed down 100 beds. On the other hand, this is, of course, only one phase of what has been called the national health problem, and the hospitals are only part of the national health policy.
That things are not as they might be we can see well enough when, in the Report of the Chief Medical Officer of the Ministry of Health the other day, it was stated that in England and Wales there is lost to the nation every year, among the insured population only, and excluding losses due to sickness for which sickness and disablement payment is not payable, the equivalent of the work of 270,000 persons. I am bound to say that I think there is a clear case for the renewal of the mandate of this Committee, and for the extension of its reference. What has been done now will not do much more than cover the year's deficit; and vet the causes lie so deep that, unless the problem be considered as a whole, and considered now, the waste of public money will be great and the results are not likely to be satisfactory. All of those who are connected with the administration of our voluntary hospitals were pleased to know that the Committee emphatically affirmed and approved the voluntary principle. It is not only a matter of lay opinion, but we know that all the experts, speaking in the various conferences that are held, hold and believe that it creates a free and expansive atmosphere for medical research and medical treatment, and that if we were to substitute for it State control, or even municipal control, it would crab and stereotype the methods of administration, and be fatal to scientific advance, as well as to expert treatment.
But what I want to persuade the Minister who is speaking on behalf of the Ministry of Health is that there is a clear case for asking the Committee to report on two great subjects, which are not only ripe for consideration but are long overdue.

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It is true that one of them was touched upon in the Report of the Committee. I mean the relation that the system of national health insurance bears to the rest of the problem of national health, and, particularly, to the provision of hospitals, both general hospitals and special hospitals; and, secondly, as I have set down in the latter part of my Question, the relation of the poor law infirmaries to the voluntary hospitals.
In regard to the question of insurance, Lord Cave's Committee quite definitely states that hospital benefit was not provided for in the Act of 1911, or in the amending Acts, and that it is not a hospital risk against which insurance was made. The section of the Act was quoted in which it is laid down that all that the insured person has a right to expect is the sort of treatment and relief the general practitioner can give in the course of his ordinary duties. I venture to think that that is very much under-stating the case. In the first place, it is laid down in the Act that the Approved Societies, as well as the municipal and local authorities generally, can make contributions to the maintenance and support of hospitals. It is recognised that hospital treatment is necessary as part of the general relief given to insured persons, many of whom are well within the category of the sick poor. But, more than that. I do not thank that the Committee appreciated the degree to which the obligations and the burdens of hospitals have been increased by the National Insurance Act. Nobody disputes that the health of the country has been vastly bettered, and the national welfare greatly advanced. by the operation of that Act., now- ten years old. But hospital treatment was absolutely necessary to the obtaining of these satisfactory results.
It is not the case that the general practitioners have given all that the Act demanded, or all, perhaps, that they might have given, if it had not been for the good will and the zealous assistance of the hospital authorities. Before the Act was passed a vast amount of sickness and distress was hidden in the back streets of the great cities and never brought to light. Much of it in the country villages never obtained proper attendance, still less remedial treatment. When the general practitioners, or the panel doctors, as they are called, began to appreciate the extent of their duties, they found ready to their
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hand, especially in the Metropolitan area, the great system of voluntary hospitals, to which they could turn if they were in the least difficulty; and there grew up the practice of sending their patients to hospital with letters of recommendation which, as a rule, ensured the cases being dealt with, even when they were not of great urgency, and sometimes even where their ailments could be described as minor ailments. When the Act was passed the whole system of prophylactic treatment, of anticipating rather than meeting sickness, was only slowly appreciated. It is said that the utility of our hospital system is decided, not by the number of beds that are full, but by the number of beds that are empty. The consequence is that, as a matter of fact, the Exchequer is getting indirectly the benefit of a vast amount of hospital expenditure which would neither have been necessary nor demanded if the National Insurance Act had not been passed into law.
The calls upon the hospitals are increasing. As everybody knows, the special consultants are now going into a sphere of treatment which was formerly left to the general practitioner, and as disease is diagnosed with greater fullness and accuracy, so the demand for skilled treatment is always increasing. I believe I hat a clear case exists under the Act for obtaining a contribution out of the surpluses of the Approved Societies, such as may not be possible at present without an amendment of the law. Lord Cave's Committee rejoices in the fact that one of the Approved Societies is appropriating for this purpose part of its surplus. It is doing so voluntarily and legally under the Act. But what is good in the case of the National Deposit Society (I think) is good in the case of the other Approved Societies. Many of them prefer, with the keen competition that exists in obtaining members, to distribute their surplus by way of casual benefit— in truth, by monetary inducements to join—rather than to do their duty and help the hospitals to the extent of the great amount of relief to the sick poor that the hospitals give.
I cannot believe, when the changed conditions of medical and surgical treatment are considered, that the Ministry of Health will be satisfied to leave the hospitals without a large contribution from the great surpluses now being accumulated, and which have already been accumulated,

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by the Approved Societies. But there has been this new factor. During the war the vast bulk of the people, and especially those who enlisted in the Forces, came to demand a higher standard of medical treatment, and received it. They are not willing to revert to the old order, and are not satisfied now merely with the panel doctor, not at his best but at his worst. They frequent the out-patients' department of the hospitals in greater numbers than they did, and in that way, even although in some cases they have to pay a small fee, the Insurance Fund has benefited materially by the lessons of the war, which are relieving the insurance Fund of what is, I think, a legitimate payment on this account.
Therefore, I do ask that the Ministry of Health will have this problem further investigated. It does not seem to me that there is very much likelihood, in regard to the London area, of the system of mass contributions coming to very great figures. Sometimes it is forgotten that at least the twelve general hospitals, which have schools attached, are doing a great deal of work which is in no sense confined to the sick poor, either in their own area or even within the bounds of the Metropolis. They are training schools for the medical profession of the whole Empire, and, of course, they have provided there the means for enabling medical students to obtain the practical demonstrations that are requisite in order to fit, them for the work of their profession. Take Cambridge University, for example. There, in the medical school, they cannot fully equip a man for the practice of medicine, because, although theory can be taught, it is obvious that they have not what I may call, with respect, the materia medica for the purpose.
That is also true, of course, of another great branch of their work. It is left for them to take upon themselves the whole of the medical research, which is now increasing in importance every day. That is a matter not only of national but of Imperial importance. It is freely stated, and claimed, that the voluntary system of our hospitals has enabled medical skill and genius to be developed so far and so fast that in those matters we are ahead of the rest of the world. If that is true, it is mainly because the twelve great general hospitals of London, with others added in Edinburgh and one or two of the great cities, have carried out this urgent research and experiment, and they are doing it, of course,
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at the expense and by the good will of those who subscribe to their funds. There is a clear case, it seems to me, on that ground alone—because the equipment of the general practitioner throughout the country is being raised, year by year, by the experience of what is being done in the hospitals, and by the knowledge that is imparted to him, directly or indirectly, through the medical journals—that they should receive fair payment out of the great surpluses of the Approved Societies.
That is one point on which I ask for further investigation. The second is, of course, the relation of the Poor Law institutions to the voluntary hospitals. This is not a new question. It is left over from decade to decade, although nobody knows better than the Minister of Health that there is infinite waste and confusion caused by its not,being solved, or even attempted to be solved, by legislation. The Royal Commission on the Poor Law reported in 1909 that it was a matter of urgency. They also, and your Lordships will pardon me if I give a short quotation, said that in the past the local authorities of the country contributed considerably to the voluntary hospitals, because in old days they had been responsible for the treatment of those within the provisions of the Poor Law.
They said that "the hospitals received patients from the parish at a fixed charge, and patients generally were charged for indoor treatment "; that London was generally divided into voluntary dispensary areas; that the general dispensary in the eighteenth century, and later, was used as a centre of teaching, and that the physicians and surgeons attended daily to give advice to such persons as came properly recommended," and they "afterwards visited the home patients at the place of their abode as the case might require." The Commissioners say that the system was continued until 1851, and they give the history of the Poor Law under the Metropolitan Poor Act of 1867, by which asylums and dispensaries generally were established.
But the point is that even twelve years ago they were very much impressed by the fact that there was a new social stratum not accustomed to go to Poor Law institutions, but which are now frequenting them in London, Liverpool and some of the other great towns. They said that these Poor Law infirmaries were no longer

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Poor Law hospitals, but general hospitals. In many eases, in the outlying districts of London, accidents and urgent cases were taken there because, as your Lordships know, owing to the historical process of growth the great hospitals of London are largely concentrated in the central area, and what is true of London is also true of other cities. Therefore, the Poor Law infirmaries are being used for doing part of that work, dealing with casualty cases, which is supposed to be done by the voluntary hospitals. At the end of their Inquiry they gave a summary of the evidence, and they said: "We are hopeful it will do much to bring the voluntary hospitals into closer cooperation with the State-supported hospitals." They do not call them Poor Law infirmaries but State-supported hospitals.
If nothing more is done, and things are left until there can be a general reform of the Poor Law system—a revolution in our local administration, for that is what it means—I think we shall have td wait many a long day before any proper system of connection or relation between the Poor Law institution and the voluntary hospital is brought about. The great loss is this—that half the deficit for which provision is being made by Parliament, and towards which the Government are recommending a grant of half a million of money, is on account of building and development. Supposing you can bring the Poor Law infirmaries into their proper place, half that money would not be required.
THE EARL OF ONSLOW: The money is not for development and building, but for carrying on.
VISCOUNT BURNHAM: At any rate, a quartet of a million of money stands for schemes which have already been approved by the Distribution Committee of King Edward's Fund, and for which money is now required. I wish to revert to the point that, a good deal of this money might not be required if you were able to put the Poor Law infirmaries in their proper place as part of the general system of medical relief, not only in London but elsewhere. As a matter of fact, there are 90,000 beds in the Poor Law infirmaries of the country, and there are 20,000 in London alone. I do not wish to say anything to the detriment of their administration, but it is known that they are disqualified at present, for many reasons, from doing all the work which must be done, in accordance with
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expert opinion, in the general hospitals. The figures are far in excess of anything that is provided in the general hospitals. It is stated in the Report that the number of beds in the general hospitals in 1920 was 12,797 in London, 31,265 in the rest of England and Wales, and 8,132 in Scotland; making a total for the whole of Great Britain of 52,194. The beds in the Poor Law institutions largely exceed those provided in the hospitals. Half of them are not full; half of them are never used in the year. Even when they are used there are not the consultants or the specialists available, as there used to be in the old days when the pauper eases were dealt with in the general hospitals. They are not available for the graver sorts of disease and major operations. In regard to other matters, the equipment is not in every case, but often, quite inadequate to the general. trend of hospital work.
I think there is a very strong case for taking special action, apart fron the general consideration of the Poor Law, in regard to Poor Law infirmaries. I am perfectly certain that there could be such a co-ordination of activities and of capacities in regard to the care and cure of the sick poor as would set the whole system in order, and prevent a large waste of public money, such as is inevitable now. When you say that you are in favour of the voluntary system and against State control, if State control follows State subsidies and support, it is forgotten that, after all, the Poor Law institutions rest wholly on rate support. If the law were so amended that you could concentrate your cases of paupers (if the Poor Law still continues its nomenclature) in a certain number of Poor Law institutions and make the others available for the general purposes of treatment and relief, that, in itself, would be a great, gain.
Therefore, I feel that, so far from the Committee not. having done work that is of great value to the community, the work they have done is a strong reason for their re-appointment in order that they may take these two great parts of the general problem of public health into account. In the long run the State will save money, and I believe that the whole of our treatment of the sick poor will be infinitely improved, while at the same time the general hospitals, both of London and of the great cities, will be able, without so great a handicap as they now carry, to

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pursue those studies and avenues of research which have led to results of infinite value, not only to the people of this country but to all mankind.
THE PARLIAMENTARY SECRETARY OF THE MINISTRY OF HEALTH (THE EARL OF ONSLOW): My Lords, the question which the noble Viscount has put down on the Paper asks, in the first place, whether His Majesty's Government have fully considered the Report of the Committee of the noble Viscount, Lord Cave. I can only reply to him that His Majesty's Government have given that Report the fullest consideration. I should like to take this opportunity to express to the noble Viscount, and to the noble Marquess opposite (the Marquess of Linlithgow), his colleague on the Committee, the great appreciation which the Government feel for the admirable work which that Committee performed, and for the useful and valuable suggestions which the noble Viscount embodied in his Report. I may say that that appreciation is fully shared by the voluntary hospitals of the country. The British Medical Association, at present in session at the 89th annual congress at Newcastle, endorsed the principal finding of that Report—namely, that the voluntary system should be maintained. In that view, I need hardly say, the Government, most cordially agree.
Then, the noble Viscount opposite goes on to ask me what steps the Government are taking to put the system of voluntary hospitals on a more satisfactory footing in order to carry out the Report of the noble Viscount, Lord Cave. Since the Question was put down a White Paper, which is on the Table of your Lordships' House, has been issued by my right hon. friend, the Minister of Health, and that contains a great deal of the reply to the noble Viscount's Question. The purpose, as has been stated in the Press, is to form a Voluntary Hospitals Commission, which has already met, and the duties of that Coin-mission will be, in the first place, to administer the Government grant of £500,000, and, secondly—and this is, I think, far the most important part of their business—to assist the hospitals in maintaining the voluntary system. The constitution of the Commission was recommended in the noble Viscount's Report, and the Minister has adhered to his recommendations with one exception—namely, that he has added one more member to represent
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Wales, and I am glad to say that my noble friend, Lord Clwyd, has accepted the position of representative of Wales on the Commission.
Of course, the Commission sitting in London, however energetic they may be, cannot really direct matters throughout the provinces, and they must have their liaison, their agents in the provinces, throughout the whole country which they seek to assist. It is proposed, in accordance with the recommendations of the noble Viscount, to constitute throughout the country local committees to deal with this question. It is proposed to take the counties as the basis for these local committees, as recommended by the noble Viscount. Possibly, the larger county boroughs will have their own committees, and perhaps two or three counties, which have not so many hospitals as others, will be joined together. The smaller county boroughs will probably be joined with the county in which they are situated. But, of course, these are all matters which are now under the consideration of the Commission, and I cannot give a categorical statement in regard thereto.
We are hoping to get the most representative committees we possibly can; that is to say, representatives of all those who are in touch with the voluntary hospitals, who are interested therein in every way—representatives of the medical profession, of the hospital boards of management, of employers, of employed, of local authorities, and of women. I think that in regard to the last-named category we have a field of hospital administrators which has, as yet, not been properly touched. There is a vast number of ladies who, during the war, acted as commandants of hospitals, some of them with as many as 100 and more beds, and others with a smaller number, some housing, perhaps, only ten or eleven convalescents. All those ladies were charged with the duty of administering their hospitals on an economical system, which was laid down for them, and on which they bad to report; and I think the experience gained there will be of great value to the local hospital committees.
Now I come to the question of finance. The noble Viscount, I think, was under a slight misapprehension. The recommendations of Lord Cave's Committee were that the Government should grant £1,000,000 this year, and should consider

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the question of further help next year. The noble Viscount's Committee further recommended that the Government should make grants on the £ for £ system in regard to hospital extension. But the Government have decided that they ought not to contribute towards building schemes at present, when the hospitals are not paying their way and the cost of building is steadily falling. They are not able to accept that recommendation, but they accept the recommendation of contributing to the cost of the running expenses—the deficit—particulars of which will be found in Appendix A of the noble Viscount's Report.
The noble Viscount; will correct, me if I am wrong, but I understand that the reason for fixing £1,000,000 was this. At the end of the year 1920 the hospitals had received grants from King Edward's Fund, the National Relief Fund, the British Red Cross Society Central Fund and. other sources, which had placed them in a position not inferior to that which they enjoyed before the war—that is to say, that their post-war deficit was, on the whole, fairly met. But with the end of the year a new state of things arose, because all those funds were exhausted and there was no more money left to subscribe to the help of the hospitals from voluntary sources. The deficit in 1920 of 672 hospitals making returns in Appendix B amounts to £.1,038,318 and that, I think, was the basis of the calculation of the sum which the noble Viscount fixed as necessary to finance the hospitals over the year.
If your Lordships will turn to the White Paper you will see that the Government have decided that, in the present financial condition of the country, they must be content to contribute only £500,000 in aid of the deficit, and must rely upon the public to provide the rest. That is to say, they hope that public subscriptions will suffice to provide the new money to meet the deficits of the hospitals. I need hardly say that the Commission and the local committees are there to assist the hospitals in every way in raising that money, and suggestions are contained on page 3 of my right hon. friend's letter which is in your Lordships' hands.
Now I venture to glance at the immediate work which will occupy the attention of the Commission. As the noble Viscount has pointed out, there are a number of hsopitals, mainly in London, I think—he mentioned the London Hospital, King's
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College and one or two others—which are in such a state that they have to close beds owing to lack of funds. The duties of the Commission will be to deal with the situation at once, and to make such advances from the Fund as will enable them to carry on, at any rate for the present, and to relieve their most immediate wants. As we all know, King Edward's Fund is in being, and it is proposed that King Edward's Fund shall take the place of the local committees in the provinces and shall act as the local committee for London. In fact, we have already asked the authorities concerned to take the necessary steps to make enquiries with regard to those hospitals which are in immediate need of assistance and to report to the Commission with as little delay as possible.
May I turn for a moment to the general functions and duties of the Commission and the committees. In doing so I should like to say very emphatically that this Commission and these committees are in no way intended to exercise control over the hospitals. They are there to help the hospitals, and not to manage or control them. We want to save the voluntary system, to put it on its legs again, and get it going as it was in the old days. We do not want to control or to run the hospitals in ally way. I hope it will be understood that the local committees are there to help them and not to run them in any way; nor is the Commission in London to do so As my right honourable friend has stated in his letter, our sole intention is to administer the Government grant so as to secure that the necessity for the grant shall disappear as quickly as possible. That is the immediate duty of the Commission and the committee.
I come next to the second point—namely, the whole question of hospital areas and the sufficiency of beds and so forth in those areas. That will be a matter for the most careful consideration of the Commission and the committees; in the first place, of the committees. The question, for instance, of building extension will come before the committees and the means of carrying those extensions out and will be reported upon by them, as well as the necessity for beds in various areas. That, of course, includes the last point which the noble Viscount raised in his Question—namely, how far the Poor Law infirmaries can be asked or required to meet the need for further accommodation and to relieve the voluntary hospitals. I should like to

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give one or two figures in regard to that point.
VISCOUNT BURNHAM: Is that outside the Poor Law?
THE EARL OF ONSLOW: All the beds; there are 92,000 beds in the Poor Law infirmaries, but they are not all in separate infirmaries, Many of them are attached to workhouses. Of the total number of beds an average of 20,000 are vacant during the winter and 30,000 during the summer. I should like to give your Lordships the figures of the beds which exist in the separate infirmaries. There are 36,607 beds in separate infirmaries and on January 1 last, 9,150 of those beds were vacant. Of course, I do not know that those arc suitable beds there may he reasons why they are not actually suitable for the reception of patients. It may be they are in districts where the hospital accommodation is already sufficient and there are other reasons which have to be considered. At any rate they are there. as the noble Viscount points out, and it is quite possible that the accommodation in the infirmaries may be of very great value and assistance in relieving the hospitals.
If your Lordships will turn to paragraph 23 of Lord Cave's Report which deals with the question of Poor Law infirmaries, it will be seen that already some hospitals at Paddington, in Birmingham, Wolverhampton, Lambeth, and one or two other places, have co-operated with the infirmaries in the work of relieving patients. I should point out—I think the noble Viscount also mentioned it—that the existing Statutes impose certain limitations on the powers of Poor Law guardians and it would be necessary to introduce legislation for the reconstruction of the Poor Law before those difficulties could be entirely removed. Poor Law reform is, of course, a matter of very considerable difficulty, as the noble Viscount has pointed out, but I need hardly say that this question of Poor Law infirmaries is recognised as a very important one and we hope, when the matter has been fully considered by the local committees, that we shall be able to go a long way towards utilising to better advantage the accommodation which is at present surplus in those infirmaries. The matter which the noble Viscount has raised will be most carefully considered, and I trust that something will be done which will enable those opportunities to be used to the fullest extent. But it is a very complex and
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difficult matter, and I should be disinclined to press the Commission to ask the local committees to submit proposals until they have had every opportunity of considering the matter fully and adequately, and with special regard to the resources of their areas.
I now come to the last point which the noble Viscount raised. It is not in the Question, and I will deal with it quite shortly. This is the matter dealt with in paragraph 14 of the Report, and refers to contributions of the Approved Societies. The noble Viscount prepared an Interim Report which was issued before the main Report. I think that this is a matter upon which it would be premature for me to say anything definite at the present moment. On the last page of the Interim Report, page 4, the Committee state: "We recommend that the Ministry should make any necessary amendment in the Regulations, and should forthwith bring this matter to the notice of the Societies." The Ministry has taken action in regard to this, and I understand that the Committee of the Approved Societies and the hospitals are in consultation on the subject. The matter will come before the Commission in due course, and I can only say that it will receive the most careful consideration, as will all the matters which will tend to relieve the situation and to assist the hospitals.
LORD SOMERLEYTON: My Lords, as one connected nearly all my life with the three Central Funds for Hospitals in London perhaps I may be allowed to say one word in regard to what has fallen from my noble friend, Lord Onslow, in his thanks to Lord Cave's Committee for the action they have taken and for the Report they have brought forward. In so doing I do not speak with any authority from King Edward's Hospital Fund, to which allusion has been made today, but on behalf of the three Central Funds, the King's Fund, the Sunday Fund, and the Saturday Fund, and also from what. I myself have seen of the Central Hospital Council and of the representative members of the London hospitals who have been meeting constantly in the last few days. I am sure they are highly pleased and delighted with the splendid Report which has been submitted.
May I say one word with regard to another point raised by my noble friend opposite (Viscount Burnham). I understood him to say that he fears that the

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money which is desired to be expended by the various London hospitals in extensions and improvements may be put into bricks and mortar, while there are a large number of Poor Law infirmaries now standing vacant, or practically vacant. With regard to that I would only say that I think it is quite clear to all of us that the central authority for London will obviously have to take into consideration the fact that these Poor Law infirmaries are now more available for the use of hospitals than they were at the time when plans for extensions and alterations were originally put forward. This consideration will therefore require, and no doubt will receive, the most careful attention of the central authority for London.
LORD DAWSON OF PENN: My Lords, those of us who have had the pleasure of reading the Report of the Committee on the hospitals, as comprehensive as any report could be, must have been struck with the fact that the members of that Committee were firmly imbued with the necessity for economy, and that they were led to recommend the sums they did by their conviction of the urgent necessity of the hospitals. When, therefore, their first recommendation of £1,000,000 is reduced by half, we all realise that the Government have only made that reduction under the cogent pressure of financial difficulties.But in view of the fact that the money is reduced by half, I think this question arises —Would it not be wise to reconsider the basis of its distribution? I put that as a question worthy of consideration. If one takes, roughly, the number of hospitals which should be helped, and puts side by side with them the money available, it will be seen that the sum, when distributed and divided, amounts to very little in an individual case. I would, therefore, suggest that possibly it would be better to reconsider the method of distribution.
That brings me to this point. I think it is an important matter to put the teaching hospitals of this country into an entirely different schedule. Their work and functions are entirely different from those of the other hospitals. The voluntary hospitals throughout the country have each a local function to fulfil. They are, no doubt, institutions of the greatest utility, but if they are closed, or if their work deteriorates, it is no doubt a great calamity to the district in which they are situate, but the calamity is limited to that
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district lf, on the other hand, anything interferes with the efficiency of the teaching hospitals, the whole nation suffers. It must be borne in mind that the teaching hospitals provide not only the doctors and the nurses for the coming generation, but, what is equally important, they set the standard of work, and anything which impoverishes those hospitals lowers the standard of work. As a consequence, the standard of work throughout the whole country could easily be so lowered in a short space of time as to deteriorate medicine in this country for twenty years. I would urge, therefore, as the money is limited, that far more important than to consider the needs of this and that hospital —and I state this without any prejudice, because at my own hospital 200 beds are closed—is to consider the question of the teaching hospitals. I suppose they number some thirty throughout England, and I think there twelve in London.
The next question raised by the noble Viscount who opened this debate was the question of the Poor Law infirmaries. This is a question which should not be allowed to rest longer. It is a serious matter that while we are waiting for the spare time, which never comes with Governments, for trying to solve the thorny question of the Poor Law, this country is prevented from utilising to the extent that it could the resources of those institutions. The noble Viscount referred to the sick poor. I would venture to say that that is not a wide enough view to take. We are all poor now, and many of us are sick. It is not only the sick poor people, who are technically called sick here, who need institutional treatment. The number who require institutional treatment steadily increases year by year, and is going to increase, and any estimate which the noble Earl may make as to the necessities of institutional treatment will, I can assure him, he very much under the mark.
The whole tendency of modern life is to increase the need of institutional treatment. The reasons for that are various, and I think it is worth while to bring them before your Lordships. There are, first, the scientific reasons. The diagnosis of disease is no longer the work of a single individual; it is done by the co-operation of several individuals; and co-operation requires equipment and organisation, and equipment and organisation require provision. It follows that, except at great cost, the efficient management of disease

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will increasingly require institutional treatment of some kind.
The next is the economic reason. It is a curious thing that every time know ledge advances you increase complexity in the investigation of illness, and as you increase complexity in the investigation of illness you increase the cost. Every new invention costs an institution an increase in expenditure. It. follows, therefore, that every time you increase the complexity of investigation the cost goes up, and the number of people who can defray the whole cost of their illness goes steadily down. You have this curious position, the cost of the efficient investigation of illness goes steadily up and the capacity of the people to pay goes steadily down. The only solution, therefore, of the efficient investigation of disease, is an increased provision of institutional treatment, or mass production. That is the economic reason why there must be an increase of institutional treatment.
The third is the social reason. Your Lordships are well aware of the increased difficulty in all homes, which are much more difficult to manage than they were; and the more narrow and restricted the income the greater the difficulty. It is not too much to say that in some parts of the country, if the lady of the house ventures to wish to have a baby the servants very often desire to leave. Domestic difficulties are so great that that tendency will force an increasing number of people into institutions for illness.
It does not do to look at this question from the point of view of the sick poor. We must take a wider view. We must consider how far the infirmaries of the country can assist voluntary hospitals, and how far they can be utilised. I think they can be utilised in two ways, and without much difficulty. The first way in which they can be used in certain districts is by supplementing the work of the general hospitals, by arrangement. If this is to be done certain conditions should be fulfilled. One condition is that they should supplement the work of voluntary hospitals and not start business on their own. That was the criticism directed against the recent suggestion at Bradford, which aimed, in the first place, at starting a hospital system of its own in its infirmary; not to supplement the work of the voluntary hospital, but rather to rival it. That is an evil which leads to great expense, great overlapping; and I know of nothing so
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calculated to destroy the voluntary principle as to allow the poor law hospital, entirely dependent on the rates, to start as a rival institution. On the other hand, the infirmary can, by a voluntary arrangement, as has been proved, very materially supplement the health services and the voluntary hospital of a district. There is another reason why, I think, it is important that they should supplement and not supplant voluntary hospitals. It is a professional reason. The medical talent of a district nearly always centres round the voluntary hospital. You want the voluntary hospital which contains the greater talent to give a lead in treatment and medical policy.
Now I come to the second way in which Poor Law infirmaries can, by voluntary means, assist the community. It is by setting aside wings, or blocks of beds, for paying patients, or supported by paying patients. Something must be done to provide for the large class of people of small means. You need some way whereby they can have the necessary equipment and organisation on a self-supporting basis. Here you have infirmaries actually in existence which could be adapted at a small cost, and there is an opportunity of doing a really valuable piece of work. By this means blocks of beds can be opened on a self-supporting basis and these poor people of small means can be admitted at a fixed fee for upkeep.
There are certain pitfalls which have to be avoided. The first is that the board of guardians, or the body which has charge of these infirmaries, should make no provision for the medical care of these people. All the guardians should do is to provide the hotel part of the business and the nursing, equipment and machinery. The important thing is that the patient's own doctor shall follow the patient into that institution. In that way you support what I consider the central principle of all medical progress in this country, and that is the provision of the fabric side by side with freedom of relations between doctor and patient. If once you allow the guardians to provide medical aid for these patients you are on the slippery slope of municipalisation of medicine if you allow the guardians to provide reasonable accommodation at cost price for the people who need it, within a certain income limit, great advance would be made in solving the difficulties which are so prominent to-day.

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I come now, if I may, to what I may call the larger policy. At the present time, although the country is in dire need and straitened financial circumstances, I think it could be very helpful if the Ministry of Health could lay down the outlines of a policy. What is the policy that is going to guide these services, and especially the curative services, during these lean years when it is admitted expenditure must be cut down to the minimum? I suggest that there are two lines of policy—first to maintain all essential services now, not more than that; and, then, this further line of policy; we can utilise these lean years to lay down the foundations of a constructive policy which can be commenced when the finances of the country permit an advance in that direction.
I think the utilisation of infirmaries will be of the greatest value. It will meet the needs of the people now at a comparatively small cost. It may be done like it has been done at Manchester, where the guardians have, by arrangement, and with the complete co-operation of the medical profession, set up one of these private wards under the conditions which I have stated. By utilising these infirmaries we should not only help the needs of the moment, but gather valuable experience for that forward movement which must come in the further organisation of medicine in the future. When I use the word "organisation" I mean the organisation of the fabric, while retaining complete freedom between doctors and patients. I know that there are difficulties in the way of boards of guardians making these arrangements, and in that connection I suggest to the Government that they should, if possible, introduce a short—I think it would be non-controversial—Bill, which would remove the doubtful legality of boards of guardians entering into these voluntary arrangements.
I know well that it would be necessary to avoid all thorny questions of local government, as to whether boards of guardians are going to be removed in the future or not, but I cannot help thinking: that a short and non-contentious Bill —as I hope it would be—would remove all doubts as to the legality of boards of guardians and other institutions, by voluntary arrangement, making this provision for the health of the people. At the present time, I believe, it is doubtful if it is legal for any board of guardians to
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charge more than the exact cost of any inmate. In another connection, it has been found that, where infirmaries are attached to hospitals, it is very difficult to transfer patients from the hospital to the infirmary, if that patient happens to live in another Poor Law area. I cannot help thinking that difficulties of that description could be removed by a short and non-contentious measure, and, in these lean years, we should be able to gain experience which would guide us usefully in years to come.
VISCOUNT CAVE: My Lords, I do not know whether it would be agreeable to the House that I should say a few words upon the points raised. Before doing so, I should like to acknowledge, in a few words, the manner in which His Majesty's Government have accepted the Report of the Committee over which I had the honour to preside. It is a source of great satisfaction to all of us that, apart from the question of funds, to which reference has been made, the Government have in the main accepted the recommendations which were put forward, and, especially, that they have appointed the Hospitals Commission over which the noble Earl has consented to preside.
I think that of the points raised we were more interested in the question of the future of the voluntary hospitals, and of the health services of the country, than even in their temporary difficulties. I look forward to the certainty that the Hospitals Commission will be able to take a wide view of those health services, and, after the experience of a year or two, it may be in a position to make recommendations which will have a permanent effect upon the future health of this country. Questions of great interest have been mentioned by the noble Lord opposite, Lord Dawson. We have all, I am sure, listened to him with great pleasure. I should not think it right to discuss these great questions to-day, but I am sure that what he has said will sink into the minds of those who heard him. I hope that the organisation of our health system, to which he himself and his Committee contributed by a most interesting Report a short time ago, will receive more and more attention as time goes on.
I rather wish the Government had found it in their hearts to recommend a larger grant. I think all the members of my Committee were "anti-waste" members,

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and they cut down the recommendation as much as possible. But we all know the position in which the country stands, and I am sure the hospitals will do their best with the help which the Government have been able to recommend. A suggestion has been made to me, to which I do not want an answer now, that this half-million is for the current year, and that a question might arise again with regard to the year 1922. It is a point which I am content simply to throw out, without hoping for; or, indeed, desiring, an answer to be given at the present time.
I desire, mainly, to refer to two points raised by the noble Viscount opposite (Lord Burnham). With regard to the insurance societies, I did not hear the whole of his remarks, but so far as I heard them, I think I was in agreement with them. I am firmly of opinion, and I do not think the noble Viscount differs from me, that the insured person individually stands, for the purpose of hospital treatment, in the same position as other people. They, as individuals, have no less claim to hospital treatment than the persons who are not insured. On the other hand, the insurance societies undoubtedly owe a great deal, both from a pecuniary and other points of view, to the hospital work, and they are morally bound to recognise that help by making contributions to hospital funds. That is the point of view which we have sought to enforce, and I am sure it is the right one. It is accepted by many of the great societies. One of them has set an example, and others, I know, are considering their position. I strongly urge that it is their duty to come to some arrangement On the matter, and to make a contribution to hospital funds, which is really due to them, and which will be a stable and continued form of support to those great institutions.
With regard to the infirmaries set up under the Poor Law, they were, of course, outside our reference, and we could only touch the fringe of that subject by recommending some measure of co-operation between those infirmaries and the voluntary hospitals. I know they differ very much in quality. In some small infirmaries attached to workhouses the work is not, perhaps, very adequately carried out, but in other places, and especially in great infirmaries like those at Paddington, or Lambeth, or in Dudley-road, Birmingham, admirable work is being done. I think we were all struck with the amount and
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quality of that work. We saw some of the superintendents of these Poor Law infirmaries. They are great institutions. They have something like 500 beds; they treat patients for every kind of disease—except certain infectious diseases, like scarlet fever and tuberculosis—from the chronic invalid to the casualty in the street, and, with a staff which is not always adequate, they do first-rate work. I remember that in one case the superintendent himself performed the operations. He did some every day, and he had performed some that morning before he came to see us. I was struck with the cheerful way in which a man who was in charge of a great institution of that kind was still able to perform such work and to give his personal attention to the patients under his care.
Of course, these institutions need considering, and I hope they will be considered. As the noble Lord opposite said, they could help by supplementing the work of the voluntary hospitals. They have no outpatient departments; they have a large number of beds, and sometimes a certain number of vacant beds. They could put those beds at the disposal of voluntary hospitals which have a long waiting list, and, in return, they could derive great help from the hospitals; that is, from the service of the staffs of the great hospitals. They could also give facilities for students to conic and learn their work there. For the moment, the policy co-operation; and I only desire to say in conclusion that, if it is necessary, as I think it may be, to make some small modification of the law to enable co-operation to take place in the fullest degree, I hope the Government will not wait for the general reform of the Poor Law which has been foreshadowed. They can, by a very short Bill, give effect to this and other recommendations, and I trust. they will see their way to introduce such a proposal at an early date.

TRUSTS (SCOTLAND) BILL. [H.L.]
Read 3ª (according to Order), and passed, and sent to the Commons.

OVERSEAS TRADE (CREDITS AND INSURANCE) AMENDMENT BILL.
Read 3ª (according to Order), and passed.
House adjourned at twenty minutes past five o'clock.